A systematic review of home-based records in maternal and child health for improving informational continuity, health outcomes, and perceived usefulness in low and middle-income countries

Background Evidence shows that a gap in the documentation of patients’ past medical history leads to errors in, or duplication of, treatment and is a threat to patient safety. Home-based or patient-held records (HBR) are widely used in low and middle-income countries (LMIC) in maternal and childcare. The aim is to systematically review the evidence on HBRs in LMICs for (1) improving informational continuity for providers and women/families across health care visits and facilities, (2) to describe the perceived usefulness by women/families and healthcare providers, and (3) maternal and child health outcomes of using HBRs for maternal and child health care. Methods The protocol was registered in PROSPERO (CRD42019139365). We searched MEDLINE, EMBASE, CINAHL, and Global Index Medicus databases for studies with home-based records from LMICs. Search terms pertained to women or parent-held records and LMICs. Two reviewers assessed studies for inclusion using a priori study selection criteria- studies explaining the use of HBRs in LMIC for maternal and child health care. The included study quality was appraised using the Mixed Methods Appraisal Tool (MMAT). Results from all study designs were summarised narratively. Results In total, 41 papers were included in the review from 4514 potential studies. Included studies represented various study designs and 16 countries. The least evaluated function of HBR was information continuity across health care facilities (n = 6). Overall, there were limited data on the usefulness of HBRs to providers and mothers/families. Home-based records were mostly available for providers during health care visits. However, the documentation in HBRs varied. The use of HBRs is likely to lead to improved antenatal visits and immunisation uptake, and skilled birth delivery in some settings. Mothers’ knowledge of breastfeeding practices and danger signs in pregnancy improved with the use of HBRs. One randomised trial found the use of HBRs reduced the risk of cognitive development delay in children and another reported on trial lessened the risk of underweight and stunted growth in children. Conclusion There is limited literature from LMICs on the usefulness of HBRs and for improving information transfer across healthcare facilities, or their use by women at home. Current HBRs from LMICs are sub-optimally documented leading to poor informational availability that defeats the point of them as a source of information for future providers.


Methods
The protocol was registered in PROSPERO (CRD42019139365). We searched MEDLINE, EMBASE, CINAHL, and Global Index Medicus databases for studies with home-based records from LMICs. Search terms pertained to women or parent-held records and LMICs. Two reviewers assessed studies for inclusion using a priori study selection criteria-studies explaining the use of HBRs in LMIC for maternal and child health care. The included study quality was appraised using the Mixed Methods Appraisal Tool (MMAT). Results from all study designs were summarised narratively.

Results
In total, 41 papers were included in the review from 4514 potential studies. Included studies represented various study designs and 16 countries. The least evaluated function of HBR was information continuity across health care facilities (n = 6). Overall, there were limited

Introduction
Quality of care is systematically deficient in most low and middle-income countries (LMIC) such that mothers and children receive less than half of the recommended clinical care during antenatal to post-natal and paediatric visits [1]. The World Health Organisation (WHO) has recognised the need for better information systems and documentation to improve outcomes for mothers and children [2]. Delays or errors in decision-making processes due to an inadequate maternity history or case documentation can contribute to complications in pregnancy, especially high-risk pregnancies [3,4]. Pregnancy and childbirth involve several visits to healthcare providers (HCP) for ante-natal care, at the time of delivery, for post-partum care and vaccinations for the new-born [5]. These may involve different HCPs such as community healthcare workers, primary care nurses, general physicians, and obstetricians, and different health care facilities such as clinics or hospitals [6,7]. When clinical handover takes place at these transition points, adequate medical information exchange regarding patients between HCPs and patients/families is necessary for ensuring continuity of care and patient safety [8,9]. A home-based record (HBR) is a patient-held health document used to record the history of health services received by women/children, widely used in LMICs [10]. It can take various forms such as ante-natal records/cards, vaccination cards, or maternal and child handbooks and requires mothers to take the record to each visit to healthcare providers (HCP). In 2018, the WHO recommended the use of an HBR by all pregnant women to improve continuity and quality of care throughout pregnancy to child health care [11]. The primary function of an HBR in this context is to record essential information related to maternal, new-born, and child health (MNCH), including health status, visits to a health care provider, vaccinations received, and the child's growth and development. Additionally, an HBR is intended to be used at home by mothers/caregivers for managing care (looking for danger signs, as a reminder for children's vaccinations, etc.). One of the advantages of having a HBR is that all HCPs will write in the same record, which can help to reduce clinical errors and improve communication between HCPs, especially across different facilities [12]. This documented information is intended to equip all HCPs, especially frontline healthcare workers, with a standardised patient history, to make informed decisions on care and immunisation services [10].
Although HBRs has been used in many LMICs [10,13], the evidence for whether they improve informational continuity for clinicians in those settings has not been reviewed rigorously. Previous systematic reviews [5,12,14,15] have found that mothers and children with records tend to have better clinical outcomes such as improved antenatal care and reduced likelihood of pregnancy complications, and they have shown an increase in mother and child vaccination rates. Another review evaluating the effectiveness of women carrying case notes found no studies reporting the availability of records at the time of delivery [12]. Currently, there is insufficient evidence on the availability of documented clinical information for HCPs (across visits and healthcare facilities) using HBRs in LMICs. Additionally, there is little information on how HBRs are being used in routine practice in LMICs [16]. Given that, HBRs are widely implemented, recommended by WHO and often the only available medical records in LMICs, we aimed to systematically review the evidence of HBRs for women/families in LMICs. Specifically, for improving the informational continuity for HCPs across visits and healthcare facilities and communicating with HCPs and women/families. The findings can further aid in designing appropriate HBRs that can contribute to optimizing implementation of HBRs in LMICs. Further, we summarised the evidence of use and health outcomes of using HBRs by HCPs and women/families.

Methods
The protocol for this review is registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42019139365) [17].

Eligibility of studies
Each study had to meet the criteria set out in Table 1 to be included in the review. Studies needed to be done in LMICs as per the World Bank 2018 [18], have an HBR intervention for pregnant women/children such as antenatal records/cards, vaccination cards or maternal and child handbooks (MCH) and at least one measure relating to an outcome of HBR intervention such as availability of HBRs at consultations, improvements in antenatal visits/vaccination rates, etc. published in the English language.

Search strategy
We systematically searched the literature using the electronic databases MEDLINE, EMBASE, and CINAHL from database inception to September 2020. Additional database search was done in GIM (Global Index Medicus) from database inception to August 2021 to include studies from LMIC. The reference lists and citations of full-text articles were hand-searched for additional eligible references. The search strategy was developed using search terms about home-based records and country names from the World Bank 2018 [18], by income classification. Search terms included (women-held OR parent-held OR mother OR pregnant women OR caregiver) AND (record OR handbook OR card OR notes) AND a list of LMICs. The search strategy developed for MEDLINE is available in the online supplement (S1 Box in S1 File). Further, we carried out additional searches on the websites of the WHO and the Japan International Co-operation Agency (JICA).

Data extraction
Two reviewers (LJ and BD) extracted data from studies that met eligibility. LJ reviewed all extracted data. The data extracted were the study objective, population, and type of PHR, outcomes assessed, and results. Any disagreements in the data extraction were finalised after discussion with a third reviewer (SMH).

Quality appraisal
For assessing the quality of included studies, the Mixed Methods Appraisal Tool (MMAT) version 2018 [19] was used. We assessed the quality of included studies using, 'high', 'medium' and 'low' descriptors. The studies that met all five criteria for quantitative and qualitative studies based on MMAT, were termed high, while studies that met three or four criteria were deemed to be medium, and finally, studies which met one or two criteria were classified as low. For mixed methods studies, the lowest score of the quantitative or qualitative strand was taken as the overall quality of the study.

Data synthesis
Due to the wide variability of included study designs and outcomes, a meta-analysis was not conducted and the study findings were summarized narratively. The functions of HBRs in the included studies were summarized by using functions proposed by Osaki et al. [20] and Brown Studies that report only the distribution and coverage of HBRs.
Data on quality of information recorded and available such as completeness of the records, the accuracy of the information, and clarity or legibility of handwritten information.
(b) Perceived usefulness of HBR For the review, usefulness is defined as perceptions of women/family members/HCPs using HBRs, satisfaction with use, usability in terms of ease of reading or recording in the records, and or degree to which a HCP believes that using HBR improves their job, the function PHRs serve for HCPs, and women/families.
Health outcomes following the use of HBRs.
(c) Maternal, new-born, and child health outcomes as per WHO guidelines such as a change in maternal/neo-natal mortality, behavioural outcomes such as improvement in antenatal visits, improvement in vaccination rates, knowledge, attitude and practice changes https://doi.org/10.1371/journal.pone.0267192.t001 et al. [16] (Online supplement; S1 Table in S1 File) with elements that define handover communication. Therefore, functions of HBR were classified as • A Handover communication and information tool for HCPs.-as a tool for recording health care received by women/children and monitoring by HCPs during clinic visits (primary provider) and across different health care facilities (for referral and transfer of information across HCPs/healthcare facilities).
• A Handover communication and information tool from HCPs to women/families-as a tool for receiving own documented medical information of the care received from HCPs, communication on further follow-up, and own care at home.
There are different records such as maternal cards, vaccination cards, maternal and child health handbooks, etc. (Online supplement; S1 Box in S1 File) included in the review and will be referred to as HBRs.
Outcomes. The outcome variables for informational continuity were summarised as availability or patients carrying HBRs to healthcare facilities, patient perception about carrying HBRs, completeness of the HBRs, and views of HCPs about the role of HBRs in improving information availability. The perceived usefulness of HBR variables was patients' and HCPs' satisfaction in using HBR, ease of recording or reading, patients' and HCPs' on how it was important for them, etc. Additionally, outcomes were considered relating to HBR as a handover communication tool between HCPs and mothers/children, such as, maternal and child health outcomes, health service utilisation, improvement in maternal and childcare behaviours such as breastfeeding. Both quantitative and qualitative findings were synthesised under each outcome.

Study selection
The database searches (MEDLINE, EMBASE, CINAHL, and GIM) found 4964 potential studies of which 470 duplicate studies were removed (Fig 1). Additionally, 20 studies were included from the citation search. In total, 4514 titles were screened for eligible studies. Further, 892 abstracts were assessed for inclusion in the review. Finally, 41 full-text articles (40 studies presented as 41 papers) were included in the review after assessing 147 full papers. We discarded the remaining 106 articles due to the following reasons (a) not being a record for maternal and childcare (n = 9) other MCH interventions such as health education classes, training for birth attendants, etc. (n = 16), (b) not being used in LMICs (n = 57), (c) facility-based health records (n = 17) and (d) no relevant outcome data (n = 7).

PLOS ONE
Home-based records for improving informational continuity in LMICs multiple countries (Egypt, India, Pakistan, Philippines, Senegal, Sri Lanka, Yemen and Zambia) [33]. The study characteristics of included studies are provided in Online supplement (S2 Table in S1 File).

Summary of results from included studies
The major functions of HBRs, which were evaluated in the included studies, pertained to the recording of health care received by women/children by HCPs and the communication between HCPs and women/family during the health facility visit. In contrast, there were very few studies evaluating referral or information transfer across healthcare facilities/providers. Studies suggested that HBRs could be used to improve handover communication between healthcare visits for HCPs and from HCPs to women/families.

Functions of HBRs
Of the 41 studies, 30 evaluated the HBR as a tool for recording health services given by HCPs (Table 2). Only six studies evaluated the HBRs as a tool for a referral or for information transfer across healthcare facilities and eight reported on HBRs as a tool for communicating between HCPs and women/families.
A Gambian study [62] explored HCPs' views on the availability and use of documented information in the HBRs and showed that the majority of women (235/250, 94%) brought HBRs in the form of government-issued cards to the hospital at delivery. This Gambian study reported facilitators for using HBRs; these were women acting as agents who transport documented information, clear documentation, and having a designated space on the HBR for referrals. The reported barriers were little or no information being recorded, illegible handwriting, and loss of reports such as lab reports leading to gaps in information in HBRs.
Three studies reported that women/families carried HBRs across healthcare facilities, without measuring the availability at all health care facilities [23,28,33]. In a multi-country study [33] that examined documentation in HBRs at referral centres/hospitals, HCPs did not always write the actions they had taken in the HBRs. However, in the Philippines, the staff were oriented about the use of HBR for referrals and 92.4% (n = 66) of HBRs had information documented.
Two studies [41,48] explored women/caregivers' reasons for not carrying HBRs to healthcare. For example, (106/300) [41] and (41/129) [48] participants in South Africa and Kenya participants did not know the importance of HBR in health care visits.

Completeness of relevant fields
Seventeen studies [32, 38, 42, 44, 45, 48-51, 53-59, 62] examined the completeness of fields in the HBRs. Completeness was assessed using different measures (Table 3) and the fields in the HBRs were not uniform across all the reported studies. Of the 17 studies, HBRs were least assessed for completion of maternal parameters (n = 6) and most assessed for child health parameters (n = 15). The reported completeness across different studies and fields in the HBRs varied ( Table 4). The most documented information was demographic details and vaccination history [32,38,48]. The least documented information was child's vision problems [48], growth monitoring and vitamin A administration [38,48], maternal HIV status [38] and doctors' notes [32] (Table 4).
In a study conducted in Burkina Faso [44], comparing recording in HBRs versus facilitybased records, 80% (492/615) of HBRs were unrecorded for children who had been vaccinated Abud and Gaiva, 2015 The development curve was considered complete when 2 or more of the items in the handbook had been filled in (out of 4) and growth data was considered complete when the handbook included at least one weight input every three months, with a minimum of 4 records in the first year of life.

HCPs' perceptions on the usefulness of HBRs
Five studies [25,29,[31][32][33] explored the usefulness of HBRs in providing health education to women/parents by providers. Two qualitative studies found that HCPs perceived families did not use HBRs for care optimally [60,61]. HCPs reported HBRs as a useful tool for giving them confidence in providing health education [29,31,33] helping them to identify risks [33], and reminding the women/families regarding vaccination [25]. In a South African cross-sectional study [32] assessing the acceptability to nurses of a maternal and child handbook over a card, nurses were satisfied with the health information (95.6%), immunisation information (94.7%), weight charts (89.5%), and notes for both staff (91.3%) and mothers (93.9%) in the handbook. Health service utilization/uptake of services. The majority of included studies (n = 14) evaluated the effects of HBR on healthcare service utilization. The three key areas of measurement of services were vaccinations, antenatal clinic visits, and a skilled birth attendant for delivery. Two trials in Pakistan [20,21] reported a 31% (adjusted RR = 1.31, 95% CI 1.18-1.46) and 67% (RR = 1.7; 95% CI = 1.4, 2.0) improvement in the 3 rd dose of diphtheria-pertussis- Five studies demonstrated an improvement in antenatal clinic visits [23,27,33,47]. Detailed outcomes are summarised in Table 4. A trial in Mongolia [24] showed that women in the intervention group attended antenatal clinics more than the control group (RR = 1.158, 95% CI 0.876-1.532) p = 0.30. Another trial in Indonesia [23] found that after using HBR, women were more likely to receive two doses of tetanus immunisation, visit the ante-natal clinic four times, have professional assistance during child delivery and ensure that their . In a repeated cross sectional study in Indonesia the use of HBR was associated with a 3 times higher probability of using a skilled birth attendant by mother (95% CI 1.031-9.477) [36]. Further, mothers with HBR were likely to receive more medical tests [37,41], post-natal care [31,34] and health information from HCPs. Maternal, neo-natal, and child health outcomes. In a Mongolian trial [24], complications in maternal health were more likely to be identified, with maternal morbidity during pregnancy at 12.3% in the intervention group compared with 5.7% in the control group (pvalue = 0. 01). However, HBRs had no effects compared to the unspecified pre-existing system in the control group on neonatal death or stillbirths (RR 1�0 95% CI: 0�99-1.01, p = 0.512). In the three-year follow-up results in the Mongolian trial [26], small but significant reduced risk of cognitive development delay in children (OR 0�32, 95% CI 0�14-0.73, p-value = 0.007) was reported. A trial in Indonesia [23] reported lesser risk of underweight children (OR = 0.33, 95% CI: 0.12-0.94; p<0.05) or lesser risk of children with stunted growth (OR = 0.53, 95% CI: 0.30-0.92; p<0.05) for caregivers using HBR.

Handover communication and information tool for women/caregivers
Knowledge, attitude, and practice. Ten studies [23, 24, 27-29, 34, 46] evaluated the use of HBR and its effects on knowledge, attitude, and practice outcomes. One study did not report any improvement in knowledge after the use of HBR [46]. Individual study results can be found in Table 5. In general, trials (n = 2) found an improvement in complementary feeding [23] and the adoption of healthy behaviours by family members of pregnant women [24] after Table 5. Handover communication tool from HCPs to women/families.

Outcomes measured
Studies which measure the outcome

Relevant results
Knowledge, attitude, and practice

Mori et al., 2015
The majority of women did not drink alcohol (7.9% in the intervention group compared with 14.1% in the control group, p = 0.161), and approximately half of family members stopped smoking at home (51% in the intervention group compared with 60% in the control group, p = 0.048).

Aiga et al., 2016
The knowledge and practice of exclusive breastfeeding improved from 66.1% in pre-intervention to 86.7% in postintervention (P < 0.001) and from 18.3% in pre-intervention to 74.9% in post-intervention (P < 0.001) respectively.

Bhuiyan et al., 2006
Reported increased awareness of breastfeeding in the intervention group (28.7% of cases and 4.6% of controls (no pvalue)), improved awareness of danger signs of pregnancy (46.9% case and 5% control groups (no p-value)), and knowledge of recommended ante-natal care (78% case and 8.3% control groups, p < 0.05).

Yanagisawa et al., 2015
Evaluated the impact of the handbook by using difference-in-differences (DID) analysis and found that the intervention group had improved awareness of childhood illness (R = 6.2 points for anaemia, 9.9 for parasites, 7.5 for HIV transmission), knowledge of breastfeeding R = 6.2 for early breastfeeding (no p-value) and improved awareness of danger signs of pregnancy.

Baequni et al., 2016
Overall, compared with the control group, the home-based records group had more knowledge and better practices during pregnancy, delivery, and child health care (e.g., immunisation). Kawakatsu et al., 2015 Reported that possession of an HBR was associated with higher health awareness using HBR. Five pre-post studies [27-29, 31, 34] assessed the knowledge, attitudes, and practices of mothers/caregivers after the introduction of HBR. They showed an improvement in knowledge and practice of breast feeding [27-29, 31, 34], awareness of danger signs in pregnancy [28,29], and awareness of childhood illness [31]. [27-29, 31, 35] assessed the utility of HBRs to mothers/caregivers. Mothers could read the contents of HBR [28,35], discuss with husbands/partners [29,31], and record breastfeeding practices in the HBR [27,35]. In Viet Nam [27], it was found that 68.1% of HBRs (MCH Handbooks) had check-boxes on exclusive breastfeeding ticked by mothers. Focus group discussions with mothers clarified that they carried the records to all healthcare visits but often forgot to record breastfeeding practices in the HBR. In a multi-country study [33], based on focus group discussions, many mothers said that the HBR was a useful "passport" in the referral system because it led to contact with "someone who knows our problem and takes better care of us at the centre".

Summary of findings
We have summarized the available evidence on HBRs from low and middle-income countries for women/families in this systematic review; specifically to improve the informational continuity for providers and for communication between HCPs and between HCPs and women/ families and outcomes of using HBRs. In general, findings suggest HBRs are under-utilized as tools for improving information availability for HCPs across health care facilities in LMICs. Overall, there is sub-optimal recording in HBRs with exception of vaccination data. However, we have shown that HBRs may facilitate improving healthcare services uptakes such as improved antenatal clinic visits, immunisation rates, and a delivery attended by skilled healthcare personnel in LMICs. Further, there was a modest impact on maternal and child health outcomes due to the use of HBRs. The review suggested that HBRs might facilitate the detection of the risk of pregnancy complications by HCPs and have a protective effect on the cognitive development of children, possibly by early detection of developmental delays. Improved awareness of breastfeeding practices and danger signs in pregnancy amongst mothers were reported after using an HBR.
This review found the frequency with which LMIC women/caregivers carry records to healthcare visits varies. However, one of the recent studies [62] reported almost 94% of women had documentation with them at the time of delivery. This finding is consistent with reviews done in high-income countries with most women/caregivers bringing their notes to clinic check-ups [12,14,63]. The retrieval of information from poorly maintained facility-based registers in many LMICs presents an opportunity to use HBRs as a surrogate tool for documented handover information [64]. Women/caregivers who did not carry records to visits were found to be unaware of the importance of having recorded at each visit [48]. However, when HCPs insisted on having the HBR, women/caregivers brought them to visits [25]. Thus, HCPs reminder creates more awareness among women/caregivers of carrying records and thus improve the availability of records at health care visits. Additionally, women carrying HBRs to all visits, irrespective of the reason for the visit, can enable better informational continuity for HCPs, subject to all HCPs being trained to enter minimal data in them.
Although HBRs are intended to be used as complementary documents to facility-based records, the availability of HBRs at healthcare visits enables better clinical decision-making [65]. However, from this review, the overall documentation in the HBRs ranged from 11% to 92%. The least utilized fields were doctors' notes, child growth, and development data, maternal HIV status, and high-risk pregnancy status. However, there are not enough data from these papers to conclude reasons for poor data entry by HCPs. To be useful for all HCPs, HBRs must be completed accurately and capture the necessary clinical information in a standardized manner. The Mongolian trial showed evidence of HBRs facilitating detection of pregnancy complications [24]. However, the limited evidence on medical information availability for HCPs in hospitals or secondary care shows that for HBRs to be useful for handover, referral using HBRs must be an established practice [20]. These results indicate the need for better training for HCPs to ensure better utilization of these records. This could be most useful in pluralistic health systems, where referral pathways are not implemented or adhered to and when patients/families self-refer themselves to different HCPs. Additionally, HBR stock-outs [66] and fragmentation of information due to multiple HBRs per patient [67] act as barriers for recording and maintaining HBRs as an established practice. Therefore, it is necessary to consider the best way to implement such a programme and if there can be a secure system for keeping it going in a way that allows for all to have one HBR and for every HBR to have the full and latest information on it. Otherwise, the cost-effectiveness and benefits of the system are questionable.
The evidence suggests that healthcare utilisation is improved with HBR in LMICs. This result is consistent with previous findings from prior systematic reviews. Magwood et al. found that HBRs had statistically significant effects on improving antenatal care attendance; however, the evidence base was small and of low to very low certainty [14]. The mechanism of improvement of healthcare utilization is unclear. This is because the RCTs [21,22] showing improvements in vaccination uptake demonstrated that this was due to HBR intervention and verbal reminders from HCPs. Therefore, whether having the information in the HBR is functioning as a trigger for HCPs to provide verbal reminders and health information, or whether patients' engagement with the records is acting as a reminder, is not well established. This is an important research gap; addressing it will enable alignment of the content of the HBRs to the literacy levels of parents or HCPs and with the function, it serves each user group. Overall, the results obtained (such as improvements in vaccination uptake) from relatively minor studies from specific geographical settings make it difficult to generalize the findings to all regions in LMIC and suggests lower certainty of the outcome.
From the review, HCPs find HBRs useful for health promotion and healthcare communication with women/families. However, limited studies [29,33] reports on HBRs improving the communication of women/caregivers with HCPs. This finding contrasts to studies in HICs, which suggest that HBRs enhance women's feeling of empowerment and thereby enable better communication with HCPs [5,12]. Additionally, there is limited evidence for pregnant women reading and recording data in HBRs from the review. Therefore, further studies, which explore the mechanisms by which behaviour change occurs with HBRs, are necessary to determine the type of health education material in them [16]. However, there is modest evidence of HBRs improving communication with husbands/partners/families. This finding is similar to a qualitative review by Magwood et al., which suggests HBRs improved engagement with care for husbands and families [15]. Therefore end users' involvement in re-designing HBRs may enable better engagement from women/families (particularly with lower literacy) and providers [68]. A user-centred design could overcome the needs and facilitate a better understanding of the users [16].
Implications for research and practice. Our findings highlight the need for engagement with end users such as frontline workers, health care providers, patients and families while designing an HBR. Additionally in those LMICs with existing HBRs, implementation evaluations of HBR use and re-formatting or re-designing the content of HBR to meet the needs of end-users will enable better use of HBRs in routine practice. Further research is needed to understand the unused content in HBRs.

Strengths and limitation.
The comprehensive search strategy for, and focused review of, studies in LMICs has helped to understand the usefulness of HBRs in that setting. However, the inclusion of studies in the English language alone may have excluded studies in regional languages. A possible limitation of this review is in the categorisation of the included studies as handover communication for HCPs and patients/families. This is because most studies contain results, which can fit into both categories. For example, the detection of cognitive delay may be due to HCPs recording and monitoring growth and parents being aware of the milestones and communicating this during healthcare visits to HCPs. Therefore, a clear distinction of the function of HBRs for HCPs alone, particularly in the absence of trials focused on the improvement of information available for providers, could not be made, calling for more research to enable an improvement in continuity of information and maternity care. This review has not evaluated the content and design quality of HBRs that may hinder the utility of HBRs for providers. However, in assessing the completion of records, it was found that the fields were different for HBRs from different countries. Therefore, having a minimum criterion, which is necessary for handover across HCPs will enable future studies to assess the quality of documented information. Additionally, this review did not capture the different health education/promotion messages included in each of HBR and its appropriateness, which can affect the MCH outcomes measured.

Conclusion
Overall, there is a lack of studies from LMICs examining the use of HBRs in improving health outcomes, which is consistent with previous systematic reviews. The findings from the review demonstrate a lack of literature on the availability of HBRs for secondary encounters such as referrals. Our study extend the evidence on current use of HBRs in LMICs for improving informational continuity for HCPs. Although there is a great potential for HBRs to enable information transfer for safe continuity of maternal and child care, evidence suggests that data completeness in the HBRs is currently suboptimal (except vaccination data) leading to decreased informational continuity for HCPs in LMICs. The review supports the HBR [potentially] being an effective tool for handover communication from HCPs to women/caregivers, in improving utilisation of antenatal visits, immunisations, and skilled birth delivery in LMICs similar to the findings from previous reviews. There is some evidence on improving mothers' knowledge of breastfeeding and identification of danger signs in pregnancy.
Supporting information S1 File. S1 Table: Functions of home-based records (HBR), S1 Box: Different types of HBRs included in the review, S2 Table: Characteristics of included studies, S3 Table: Results